Corporate

Resolved Fiscal Intermediary Standard System Claims Processing Issues

Updated: 11.13.19

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.14.2019

Closed

Hospice

Hospice providers may notice that the information provided in the Interactive Voice Response (IVR) system and myCGS may not reflect all current hospice periods. Please refer to Change Request 11277 for additional information.

NA

NA

10.16.2019

Updates

10.16.2019 – The resolution was implemented on October 7, 2019.

09.26.2019 – No additional update at this time.

09.06.2019 – No additional update at this time. A resolution will be implemented October 7, 2019, based on Change Request 11277.

08.16.2019 – No additional update at this time. A resolution will be implemented October 7, 2019, based on Change Request 11277.

07.23.2019 – No additional update at this time.

06.18.2019 – No additional update at this time.

05.29.2019 – No additional update at this time.

05.14.2019 – Change Request 11277 is to be implemented October 7, 2019.

MAC Action

12.04.2018 – CGS has reported this issue to the Common Working File (CWF).

Provider Action

05.14.2019 – No action at this time. Be sure to use the Common Working File (CWF) eligibility screens (ELGA or ELGH) to research hospice periods.

Proposed Resolution 05.14.2019 – Refer to the Change Request 11277External PDF which is scheduled for implementation October 7, 2019

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.09.2019

Closed

All Part A, Part B, home health and hospice providers

CGS has been notified by CWF that beneficiary eligibility dates may be missing from the CWF beneficiary files. They have received many examples and will be looking into the issue. This will affect eligibility inquiries using the myCGS portal, Interactive Voice Response (IVR) system and the CWF eligibility systems, ELGA/ELGH.

NA

Eligibility

10.15.2019

Updates

10.15.2019 – Due to processing issues at the Enrollment Database (EDB) entitlement data sent for new and/or updated beneficiaries processed at the Common Working File (CWF) between October 7, 2019 and October 9, 2019 posted with blank/ZERO entitlement dates causing some claims to reject with reason code U5200. After discovering the issue, CGS suspended some claims. The issue with the EDB has been corrected and the beneficiary entitlement dates have been restored. Please refer to the Provider Action and MAC Action section below for additional information.

10.09.2019 – Additional information will be provided when it becomes available.

MAC Action

10.15.2019 – Claims that were suspended with reason code U5200 will be released to continue processing.

10.09.2019 – No action at this time.

Provider Action

10.15.2019 – If you had claims reject with reason code U5200 as a result of this issue, please verify that the beneficiary was eligible on the date of service and the claim was rejected incorrectly, and resubmit the claim to CGS for processing.

10.09.2019 – No action at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.11.2019

Closed

Hospice

CGS is aware that Notices of Election (NOEs) are RTPing with reason code 32114 when the 9-digit ZIP code is not transmitted via EDI submission. NOEs submitted via DDE are currently processing correctly.

32114

RTP

08.19.2019

Updates

08.06.2019 – This issue has been resolved.

07.30.2019 – No additional update at this time. A resolution to this issue is scheduled for implementation on August 19, 2019. Refer to the Provider Action section below.

07.16.2019 – A resolution to this issue is scheduled for implementation on August 19, 2019. On August 20th, NOEs submitted via EDI submission should process without editing for the ZIP code.

MAC Action

07.30.2019 – A resolution to this issue is scheduled for implementation on August 19, 2019.

07.11.2019 – CGS is currently researching.

Provider Action

07.16.2019 – Providers may correct their NOEs that are in RTP with reason code 32114 by entering the full 9-digit ZIP code. CGS will also accept late NOE exceptions for this specific issue. When requesting an exception, enter Remarks stating "NOE was incorrectly returned due to the ZIP Code issue with reason code 32114."

07.11.2019 – Ensure that the full 9-digit ZIP code is transmitted. Please check this log for additional updates concerning EDI submission of NOEs.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

12.04.18

Closed

Hospice

Hospice claims are incorrectly rejecting with reason code C7080.

C7080

NA

05.14.2019

Updates

05.15.2019 – This issue has been resolved. Claims are no longer being rejected incorrectly.

04.25.2019 – No additional update at this time.

04.09.2019 – No additional update at this time.

03.25.2019 – No additional update at this time.

03.08.2019 – No additional update at this time.

02.21.2019 – No additional update at this time.

02.08.2019 – No additional update at this time.

01.18.2019 – No additional update at this time.

01.04.2019 – No additional update at this time.

12.04.2018 – Hospice claims are incorrectly rejecting with reason code C7080 indicating that one or more line item date of service overlaps with another claim.

MAC Action

12.04.2018 – CGS has reported this issue to the Common Working File (CWF).

Provider Action

05.14.2019 – No provider action is required.

12.04.2018 – No provider action is required at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.15.2018

Closed

Hospice

Hospice claims are receiving reason code U5175 incorrectly.

U5175

NA

05.14.2019

Updates

05.14.2019 – The CGS Claims department are now able to work the claims suspended with reason code U5175 to allow continued processing.

04.25.2019 – No additional update at this time.

04.09.2019 – No additional update at this time.

03.25.2019 – No additional update at this time.

03.08.2019 – No additional update at this time.

02.21.2019 – No additional update at this time.

02.08.2019 – No additional update at this time.

01.18.2019 – No additional update at this time.

01.04.2019 – No additional update at this time.

12.11.2018 – No additional update at this time.

11.15.2018 – Hospice claims receiving reason code U5175 incorrectly are being suspended in status/location S M90HP. U5175 suspends when a hospice transaction reverses a hospice revocation that will result in overlapping hospice election periods.

MAC Action

05.14.2019 – Claims suspended with reason code U5175 are being worked to continue processing.

11.15.2018 – Updates will be provided as they become available.

Provider Action

05.14.2019 – No provider action is required.

11.15.2018 – No provider action is required at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.17.2019

Closed

Home Health and Hospice

Claims submitted with a patient's Health Insurance Claim Number (HICN) rather than the Medicare Beneficiary Identifier (MBI) are not populating to the Standard Paper Remittance (SPR) although the information is showing on the 835 file.

NA

HICN

04.25.2019

Updates

04.25.2019 – The correction to this issue has been implemented.

04.17.2019 – The correction to the issue will be implemented into production on April 22, 2019.

MAC Action

04.17.2019 – The fix for this issue is scheduled to be implemented into production on April 22, 2019.

Provider Action

04.17.2019 – Providers may bypass this issue by submitting claims with the MBI. Only claims submitted with the HICN are not populating the patient's name on the SPR.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.10.2019

Closed

Home Health and Hospice

The Medicare Part B payment allowances for HCPCS code Q2038 and CPT code 90661 (flu vaccine) is not yet available.

37580 and 36602

HCPCS code Q2038 and CPT code 90661 (flu vaccine)

04.25.2019

Updates

04.25.2019 – Products described by these codes have not been available since 2016; therefore, the Centers for Medicare & Medicaid Services (CMS) do not have a payment amounts for these codes. Claims with these codes will be sent to the Return to Provider (RTP) file with reason code 79079 for providers to correct the claim with a valid code.

04.09.2019 – No additional update at this time.

03.25.2019 – No additional update at this time.

03.08.2019 – No additional update at this time.

02.21.2019 – No additional update at this time.

02.08.2019 – No additional update at this time.

01.14.2019 – The CPT code 90661 has been added to this issue.

01.10.2019 – Claims with dates of service on or after August 1, 2018, through July 31, 2019, submitted with HCPCS code Q2038 (flu vaccine) are being suspended in status/location S MFLU1. Refer to MM10914External PDF for additional information.

MAC Action

04.25.2019 – CGS will send claims to the RTP file with reason code 79079 in order for providers to correct.

01.10.2019 – Claims are being suspended in status/location S MFLU1 until the payment allowance is available.

Provider Action

04.25.2019 – Providers will need to correct claims in RTP with reason code 79079 by correcting the HCPCS code.

01.10.2019 – No action is necessary by providers.

Proposed Resolution

01.10.2019 – Once the payment allowance is available, claims will be released to continue processing.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.01.2019

Closed

Home Health and Hospice

The Common Working File (CWF) eligibility inquiry screens (ELGA/ELGH) are not allowing providers to access eligibility information.

NA

ELGA/ELGH

04.02.2019

Updates

04.02.2019 – This issue has been resolved. Providers may now access eligibility information via ELGA/ELGH.

MAC Action

04.01.2019 – CGS is currently researching the issue.

Provider Action

04.02.2019 – No provider action required.

04.01.2019 – Providers may obtain eligibility information by accessing myCGS or the Interactive Voice Response (IVR).

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.05.2019

Closed

Hospice

Some hospice adjustments continue to process with incorrect two tier (high/low) payment rates for Routine Home Care services.

 

Routine Home Care (RHC)

03.08.2019

Updates

03.08.2019 – The resolution scheduled for 3.4.2019 has been implemented. Providers may resubmit adjustment that previously paid incorrectly.

02.19.2019 – No additional update at this time.

02.05.2019 – This issue has been reported to the system maintainers. A resolution to this issue is scheduled for implementation on 3/4/2019.

MAC Action

03.08.2019 – No action.

Provider Action

03.08.2019 – Providers may resubmit adjustment that previously paid incorrectly.

02.05.2019 – No action is required at this time.

Proposed Resolution 02.05.2019 – A resolution will be implemented on 3/4/2019.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

12.19.2018

Closed

Home Health

CGS has identified home health Requests for Anticipated Payments (RAPs) and final claims are being sent to the Return to Provider (RTP) file with reason code 1A005 (patient middle initial invalid). When some claims are selected to view in FISS Direct Data Entry, the claim screen is blank.

1A005 (patient middle initial is invalid)

NA

02.04.2019

Updates

02.08.2019 – The 02.04.2019 system release was implemented to resolve this issue. See "Provider Action" below.

01.18.2019 – The 01.17.2019 system release has been moved to 02.04.2019.

01.04.2019 – Two separate system releases have been scheduled for 01.07.2019 and 01.17.2019.

12.19.2018 – CGS is currently researching this issue. Updates will be provided as soon as they become available.

MAC Action

02.08.2019 – The 02.04.2019 system release was implemented.

Provider Action

02.08.2019 – The system releases should prevent future blank claims; however, the release does not resolve RAPs and final in RTP with reason code 1A005 or 1A006. Take the following actions to generate a beneficiary file to allow the blank RAPs or claims to finish processing.

  • Resubmit the RAP
  • Resubmit the final claim
  • Call the Provider Contact Center (PCC) at 1.877.299.4500 to add a beneficiary file.

12.19.2018 – No provider action is required at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.24.2018

Closed

Hospice

CGS has identified an ongoing issue with the two tier (high/low) payment rates for Routine Home Care services.

NA

Hospice Payment Rates for Routine Home Care (RHC)

12.03.2018

Updates

01.04.2019 – A resolution to this issue was implemented on December 3, 2018.

12.11.2018 – No additional update at this time.

11.13.2018 – No additional update at this time.

10.24.2018 – It appears that the implementation of the October 2018 system release may not have resolved this issue. CGS and technical services are currently researching claims that have had the two tier payment rates applied incorrectly.

10.03.2018 – This issue was resolved with the implementation of the October 2018 system release. Refer to the Provider Action section below.

08.30.2018 – No additional update at this time.

08.16.2018 – A resolution is scheduled for October 2018. Refer to the "Provider Action" section below.

MAC Action

01.04.2019 – No action by CGS is required.

Provider Action

01.04.2019 – Providers may submit adjustments to claims affected by this issue.

10.24.2018 – If you identify a claim that received an incorrect payment on RHC services, submit a Medicare HHH Reopenings Adjustment Request Form for each of the impacted claims. In the Reason for Request "Other" section of the form, please indicate "RHC 2-tier" payment error". Once received, CGS will initiate the internal process to correct the payment.

10.03.2018 (Updated) – An adjustment needs to be made to claims/adjustments that were processed prior to the October 2018 system release. If the new adjustment did not change the payment as expected, please contact the Provider Contact Center (PCC) at 1.877.299.4500 to remove the CWF overrides.

08.16.2018 – If you identify a claim that received an incorrect payment on RHC services, submit a Medicare HHH Reopenings Adjustment Request Form for each of the impacted claims. In the Reason for Request "Other" section of the form, please indicate "RHC 2-tier" payment error". Once received, CGS will initiate the internal process to correct the payment.

Proposed Resolution

10.24.2018 – Additional research is required.

08.16.2018 – A resolution is scheduled for October 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

12.04.2018

Closed

Home Health and Hospice

Reason code 30909 is incorrectly being applied to adjustment type of bills.

30909

NA

12.10.2018

Updates

12.11.2018 – This issue has been resolved.

12.04.2018 – Affected claims will be suspended in status/location S M0909. Updated information will be provided as it becomes available.

MAC Action

12.11.2018 – The suspended claims in status/location S M0909 have been release to continue processing.

Provider Action

12.11.2018 – No provider action at this time; however, if you have a claim in the return to provider (RTP) file with this reason code, you may F9 the claim to release for continued processing.

12.04.2018 – No provider action is required at this time.

Proposed Resolution

12.04.2018 – Until this issue is resolved, affected claims will be suspended in status/location S M0909.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.01.2018

Closed

Hospice

Hospice claims are receiving reason code U5172 incorrectly.

U5172

NA

11.13.2018

Updates

11.13.2018 – The system release was implemented on 11.11.18 and the claims suspended in status/location S M90HP with reason code U5172 were released to continue processing.

11.08.2018 – Claims receiving U5172 incorrectly are being suspended in status/location S M90HP

MAC Action

11.13.2018 – Claims suspended in status/location S M90HP with reason code U5172 were released to continue processing.

11.08.2018 – Updates will be provided as they become available.

Provider Action

11.13.2018 – No action required.

11.08.2018 – No provider action is requires at this time.

Proposed Resolution

11.08.2018 – CGS anticipates this issue to be resolved with a system release scheduled for 11.11.18.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.01.2018

Closed

Hospice

Hospice claims are receiving reason code U5173 incorrectly.

U5173

NA

11.13.2018

Updates

11.13.2018 – The system release was implemented on 11.11.18 and the claims suspended in status/location S M90HP with reason code U5173 were released to continue processing.

11.08.2018 – Claims receiving U5173 incorrectly are being suspended in status/location S M90HP

MAC Action

11.13.2018 – Claims suspended in status/location S M90HP with reason code U5173 were released to continue processing.

11.08.2018 – Updates will be provided as they become available.

Provider Action

11.13.2018 – No action required.

11.08.2018 – No provider action is requires at this time.

Proposed Resolution

11.08.2018 – CGS anticipates this issue to be resolved with a system release scheduled for 11.11.18.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.29.2018

Closed

Home Health/Hospice

CGS has identified home health Requests for Anticipated Payments (RAPs) and final claims are being sent to the Return to Provider file with reason codes 1A005 (patient middle initial invalid) and 1A006 (patient date of birth invalid). When some claims are selected to view, the claim screen is blank.

1A005 and 1A006

NA

10.29.2018

Updates

10.29.2018 – A system update was implemented to resolve this issue. Please see Provider Action below.

10.24.2018 – CGS is currently researching this issue. Updates will be provided as soon as they become available.

MAC Action  
Provider Action

10.29.2018 – If you have a RAP or a claim in the RTP file with reason code 1A005 or 1A006, and the claim screens are blank, you will need to re-enter the RAP or claim information, or resubmit a new RAP or claim.

10.24.2018 – None at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.10.2018

Closed

Part B and Part A

Electronic Claims rejecting on the Front End on the 277CA report for diagnosis codes effective 10/1/2018

NA

ICD 10 codes effective 10/1/2018

10.10.2018

Updates  
MAC Action

10.10.2018 – Reloading the CCEM ICD 10 table correctly

Provider Action

10.10.2018 – Must resubmit files once the issue is resolved.

Proposed Resolution

10.10.2018 – We are in the process of correcting this issue. The CCEMs will not be producing 277CAs while we are correcting this issue. It will approximately take 2 hours to complete, ETA 1:30 pm EST.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

09.25.2018

Closed

Home Health and Hospice

Some claims are incorrectly going to the Return to Provider (RTP) file with reason code EA002 indicating the Health Insurance Claim Number (HICN)/ Medicare Beneficiary Identifier (MBI) is not valid.

EA002

Health Insurance Claim Number (HICN) / Medicare Beneficiary Identifier (MBI)

10.03.2018

Updates

10.03.2018 – This issue was resolved with the implementation of the October 2018 system release.

09.25.2018 – CGS expects this issue to be resolved with the implementation of the October 2018 system release.

MAC Action  
Provider Action

10.03.2018 – If you have claims in the RTP file (T B9997) with reason code EA002, you can F9 the claims to continue processing.

09.25.2018 – No action at this time.

Proposed Resolution

09.25.2018 – Issue will be resolved with the implementation of the October 2018 system release.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

09.11.2018

Closed

Home Health and Hospice

Some Medicare Secondary Payer (MSP) home health and hospice claims are being overpaid, as FISS is not subtracting the primary payer payment from the Medicare reimbursement.

NA

Medicare Secondary Payer (MSP)

10.03.2018

Updates

10.03.2018 – This issue was resolved with the implementation of the October 2018 system release.

09.11.2018 – It is anticipated that this issue will be resolved with the October 2018 system release.

MAC Action  
Provider Action

10.03.2018 – If you have claims that were overpaid, please adjust the claim to allow it to process correctly.

09.11.2018 – None at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.16.2018

Closed

All CGS J15 Providers

Some providers are not able to view any Greenmail letters in the myCGS portal. Links for their letters display, but providers are unable to view.

NA

myCGS

08.17.2018

Updates

08.17.2018 – Providers are now able to open letters received via myCGS Greenmail. We apologize for the inconvenience.

08.16.2018 – This issue is being researched.

MAC Action  
Provider Action

08.16.2018 – None at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.19.2018

Closed

Hospice

System issues resulted in the recent redesigned hospice election/revocation improvements implemented with the July 2018 system release as explained in SE18007. See the Updates section below for details.

U5159, U5173, U514A, U5162, U5181

Occurrence Code 27 and Type of Bill 8XC.

09.28.2018

Updates

09.27.2018 – A resolution to claims with reason code U5159 and U5162 has been implemented.

09.25.2018 – A resolution to claims with reason code U5173, U514A, and U5181 has been implemented.

08.30.2018 – A fix to the issue with reason code U5181 will be included in the October 2018 system release.

Reason code U5162 was added to this issue. The issue is being researched.

08.16.2018 – No additional update at this time.

08.09.2018 – Claims are being sent to the Return to Provider (RTP) file with reason code U5181 when the dates of service are within the current hospice benefit period at CWF.

No additional updates at this time.

08.01.2018 – No update at this time.

07.19.2018 – These issues are currently being researched and additional information will be provided when it becomes available.

  • U5159 – FISS is not allowing the use of occurrence code 27 on hospice claims to create the new benefit period on the Common Working File (CWF). Affected claims are being suspended in status/location S M90HP.
  • U5173 – The occurrence code 27 is not creating a new benefit period. Affected claims are being suspended in status/location S M90HP.
  • U514A – Hospice claims with the type of bill 8XC receive reason code U514A inappropriately. Affected claims are being suspended in status/location S M90HP.
MAC Action

09.27.2018 – CGS will move the claims with reason code U5159 and U5162 out of the suspended status/location S M90HP to continue processing.

09.25.2018 – CGS will move the claims with reason code U5173 and U514A out of the suspended status/location S M90HP to continue processing.

07.19.2018 – CMS is aware of these issues. CGS and system maintainers are currently researching these issues.

Provider Action

09.25.2018 – If you have claims in the RTP file with reason code U5181, F9 the claim to continue processing.

07.19.2018 – No action at this time

Proposed Resolution

07.19.2018 – Additional information will be provided once research is completed.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.09.2018

Closed

Home Health and Hospice Providers

Providers are unable to access eligibility information via the FISS Direct Data Entry (DDE) screen Option 10, Beneficiary/CWF.

NA

NA

07.30.2018

Updates

07.30.2018 – This issue was resolved earlier than scheduled. Providers should now be able to access CWF eligibility information using FISS Inquiry Option 10, Beneficiary/CWF.

MAC Action

07.09.2018 – A resolution to this issue is tentatively scheduled for August 6, 2018.

Provider Action

07.30.2018 – No action required.

07.09.2018 – Providers may use the IVR, ELGH/ELGA, or myCGS to access Medicare eligibility information.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.05.2018

Closed

Home Health providers

Medicare Secondary Payer (MSP) home health final claims and LUPA claims are being overpaid. Claims received after April 2, 2018 and paid after April 27, 2018 are paying without consideration of the primary payment and OTAF amounts.

NA

NA

08.22.2018

Updates

08.22.2018 – The correction to this issue was implemented on August 20, 2018.

08.16.2018 – No additional update at this time.

06.05.2018 – A resolution to this issue is scheduled for implementation on August 20, 2018.

MAC Action  
Provider Action

08.22.2018 – Providers should submit adjustments to claims that were overpaid.

06.05.2018 – No action necessary by providers.

Proposed Resolution

06.05.2018 – A resolution to this issue is scheduled for implementation on August 20, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.14.2018

Closed

Home Health and Hospice

Providers are unable to correct claims and home health Requests for Anticipated Payments (RAPs) that are in the return to provider (RTP) file with reason code U6803. In addition, home health providers are unable to enter RAPs for beneficiaries that have an open MSP record.

U6803

NA

08.22.2018

Updates

08.22.2018 – The correction to this issue was implemented on August 20, 2018. Providers will be able to submit RAPs and correct claims that are in RTP with reason code U6803.

08.16.2018 – No additional update at this time.

07.23.2018 – The implementation date for the correction to this issue has been changed to August 20, 2018.

07.06.2018 – The July 2, 2018, implementation date for the correction has been changed to July 23, 2018.

MAC Action

06.14.2018 – The correction for this issue is scheduled for implementation on July 2, 2018

Provider Action

07.23.2018 – Once the August 20, 2018 fix is implemented, providers will be able to submit RAPs and correct claims that are in RTP with reason code U6803.

07.06.2018 – Once the July 23, 2018 fix is implemented, providers will be able to submit RAPs and correct claims that are in RTP with reason code U6803.

06.14.2018 – Once the July 2, 2018 fix is implemented, providers will be able to submit RAPs and correct claims that are in RTP with reason code U6803.

Proposed Resolution

07.06.2018 – The July 2, 2018implementation date for the correction has been changed to July 23, 2018.

06.14.2018 – The correction for this issue is scheduled for implementation on July 2, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.24.2018

Closed

HH&H Providers

The Fiscal Intermediary Standard System (FISS) has identified an issue with some Medicare Secondary Payment (MSP) claims.

U6803, U6816, U6817, U6818, U6819, U681D, U681E, U681L, 39074, E61#H

Suspend in Location SM0628

09.17.2018

Updates

09.18.2018 – A resolution to the issue affecting claims with reason code U681D, U681E, U681L, and E61#H was implemented September 17, 2018. Claims held in status/location S M0628 will be released to continue processing.

09.04.2018 – A resolution to the issue with home health RAPs and reason code E61#H was anticipated for implementation on September 4, 2018. CGS has been notified that the implementation date has been changed to September 17, 2018.

08.30.2018 – No update at this time.

08.22.2018 – CGS has been notified that MSP claims with reason codes U681D, U681E, U681L will be held in status/location S M0628 until the October 2018 system release.

08.16.2018 – No additional update at this time.

07.31.2018 – MSP claims currently being held with reason codes U6803, U6816, U6817, U6818, U6819, U681E, U681L, or 39074 will be released to continue processing as usual.

MSP claims being held with reason code U681D will continue to be held. We anticipate a fix to this issue to be implemented on August 20, 2018.

Home health RAPs being held with reason code E61#H will continue to be held. We anticipate a fix to this issue to be implemented on September 4, 2018.

07.23.2018 – The implementation date for the correction to this issue has been changed to August 20, 2018.

06.22.2018 – The implementation date for the correction scheduled for July 2, 2018, has been changed to July 23, 2018.

MAC Action

05.24.2018 – MSP claims hitting an identified reason code (Reason Codes) will be suspended and not Returned to Provider (RTP). The correction for this issue will be installed into production on July 2, 2018, and suspended claims will be released.

Provider Action

NA

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Closed

Home Health and Hospice

Claims submitted for processing with a Medicare Beneficiary Identifier (MBI) that were returned for valid reasons currently cannot be corrected through the Fiscal Intermediary Shared System (FISS) Direct Data Entry (DDE) system. The issue will be resolved no later than Tuesday, July 3, 2018.

NA

NA

07.02.2018

Updates

07.30.2018 – A fix to this issue was implemented on July 2, 2018.

07.06.2018 – No update at this time. CGS is researching to ensure a fix was implemented.

MAC Action  
Provider Action

07.30.2018 – Providers should be able to correct claims out of the RTP file that were submitted with an MBI.

05.22.2018 – To avoid delays in payment, submit a new claim to CGS if an MBI claim was returned to you.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.08.2018

Closed

Home Health and Hospice

Claims are being submitted with the new Medicare Beneficiary Identifier (MBI) and the Fiscal Intermediary Standard System (FISS) is attaching an invalid Health Insurance Claim Number (HICN) to the claim, causing the claim to go to the Return to Provider (RTP) file for various reasons.

Various reason codes (e.g., 38107 or 37402)

MBI

01.18.2019

Updates

01.18.2019 – This issue has been resolved. 

12.11.2018 – No additional update at this time.

11.13.2018 – No additional update at this time.

10.03.2018 – No update at this time. The CGS Claims staff continues to manually correct claims suspended in status/location S MPMBI.

08.30.2018 – No update at this time.

08.16.2018 – The claims suspended in status/location S MPMBI were corrected by the Claims Staff; however, it has been discovered that the update implemented on July 2, 2018, did not completely fix the issue. Some claims have continued to go to the RTP with reason codes 38107 and 37402. An edit will be set up to move those claims to the suspended status/location S MPMBI.

07.31.2018 – The CGS Claims staff continue to manually correct claims suspended in status/location S MPMBI.

07.12.2018 – It has been determined that the claims suspended in status/location S MPMBI will need to be manually corrected by CGS Claim staff. This issue will be updated once all suspended claims have been corrected.

07.06.2018 – The update was implemented on July 2, 2018; however, it appears the update did not resolve the issue. Additional research is being done.

05.17.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions to suspend home health and hospice claims submitted with an MBI that receive reason codes 38119, 38107, or 37402 until an update is installed. The update is currently scheduled for July 2, 2018. The affected claims will be suspended in status/location S MPMBI.

05.08.2018 – This issue has been reported to the FISS maintainer for additional research.

MAC Action

01.18.2019 – All claims that were suspended in S MPMBI with reason codes 38107 and 97402 have been released to continue processing.

08.16.2018 – An edit has been set up to suspend claims with reason codes 38107 and 37402 to status/location S MPMBI.

07.12.2018 – It has been determined that the claims suspended in status/location S MPMBI will need to be manually corrected by CGS Claim staff. This issue will be updated once all suspended claims have been corrected.

05.17.2018 – After the update, which is currently scheduled for July 2, 2018, is implemented, CGS will release the claims to continue processing.

05.08.2018 – None at this time.

Provider Action

01.18.2019 – No action is required.

08.16.2018 – If you have claims in the RTP file with reason codes 38107 and 37402, please F9 and they will move to the suspended status/location S MPMBI.

07.12.2018 – No action by providers required for claims suspended in status/location S MPMBI.

05.08.2018 – Providers may suppress the claim showing in the Return to Provider (RTP) file with the invalid HICN and resubmit the claim using the beneficiary's correct HICN.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.29.2018

Closed

Home Health and Hospice

The Fiscal Intermediary Standard System (FISS) rejected Non-Group Health Plan (GHP) (No-Fault, Worker's Comp, and Liability) claims processed on or after October 3, 2016, incorrectly.

34133, 34134, 34137, 34138, 34139, 34140, 34141, 34142, 34143, 34144, 34145, 34146, 34147, 34148, 34149, 34152, 34153, 34154, 34299, 34300, 34304, 34379, 34381, 34383, 34507, 34508, 34512, 34544, 34545 or 34549

No-Fault, Worker's Comp, and Liability

10.01.2018

Updates

10.30.2018 – This issue was resolved with the implementation of the October system release.

10.03.2018 – No update at this time.

08.30.2018 – No update at this time.

08.16.2018 – No update at this time.

05.07.2018 – No update at this time.

04.23.2018 – CGS has been notified that the CMS instructions are being delayed until further notice.

03.30.2018 – FISS will install a fix on April 23, 2018 and claims rejected incorrectly shall be adjusted.

MAC Action

10.30.2018 – Providers may adjust any claims that were rejected incorrectly with the reason codes listed above.  Home health providers should resubmit RAPs that may have been cancelled.

03.30.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions for CGS to mass adjust claims rejected with the above listed reason codes once the fix has been installed. In addition, any Home Health Request for Anticipated Payment (RAP) processed on or after October 3, 2016 through April 23, 2018 (date fix will be installed) with reject code equal to U6816, U6817 or U6818 along with reason codes 34XXX (listed above) shall be cancelled.

Provider Action

03.30.2018 – Home Health providers will be advised when to resubmit the RAPs that were cancelled.

Proposed Resolution

03.30.2018 – FISS will install a fix on April 23, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.20.2018

Closed

Home Health and Hospice

The MAS (Medicare Appeals System), used to effectuate favorable and partially favorable Appeals, is not working appropriately to allow some claims to process and pay.

NA

Appeal Redeterminations

07.06.2018

Updates

07.06.2018 – This issue has been resolved.

05.31.2018 –No further update at this time. The MAS contractor is monitoring to report anything if any effectuations are missed. At this time no permanent fix has been implemented as expected.

04.23.2018 – The CMS MAS contractor has identified all the effectuations involved in this issue. A permanent correction is scheduled for implementation in May. Until then, a report will be run so that all effectuations are identified and are processed as appropriate.

04.09.2018 – No update at this time.

03.21.2018 – No update at this time.

03.07.2018 – No update at this time. CGS continues to work with the CMS MAS contractor.

MAC Action

04.23.2018 – See the "Updates" information above.

02.20.2018 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) MAS contractor.

Provider Action

07.06.2018 – No action is required.

04.23.2018 – No action is required.

02.20.2018 – Update: CGS is unable to identify the claims affected by this issue. Therefore, if you have received a partially or fully favorable appeal decision outside of 60 days, and have not yet received payment, please contact the CGS Provider Contact Center at 1.877.299.4500, Option 1.

Proposed Resolution

04.23.2018 – A correction is scheduled for implementation in May.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.30.2017

Closed

Home Health

The reason code 37253 cannot be bypassed for claims that are submitted with the 'DR' condition code (CC) indicating a waiver under §1135 of the Social Security Act.

37253

DR Condition Code

07.06.2018

Updates

07.06.2018 – This issue has been resolved.

03.07.2018 – No updates available until the CR 10372 is implemented on July 2, 2018.

02.09.2018 – No additional update at this time.

02.01.2018 – CMS issued MM10372External PDF "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" with information about creating a bypass with condition code DR is reported on the claim.

01.09.2018 – CMS released Change Request 10372 "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" on January 5, 2018, with an implementation date of July 2, 2018.

12.11.2017 – CMS is working to issue a Change Request to resolve this issue.

11.27.2017 – No additional update at this time.

11.13.2017 – No additional update at this time.

10.30.2017 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions to suspend home health claims after validating CC 'DR'. Periodically when a number of suspended HH claims build up, or not less frequently than weekly if any HH claims are suspended, the reason code 37253 will be temporarily deactivated. The suspended claims with CC 'DR' will be released for processing, and then the reason code will be reactivated.

MAC Action

10.30.2017 – This process will continue for as long as claims for dates of service subject to the waiver are timely or until the reason code can be revised.

Provider Action

07.06.2018 – No action required.

10.30.2017 – None

Proposed Resolution

01.09.2018 – CMS released Change Request 10372 "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" on January 5, 2018, with an implementation date of July 2, 2018.

10.30.2017 – CMS will add a bypass for CC 'DR' to reason code 37253 in a future Change Request, so this workaround will not be needed in the case of future emergencies.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.07.2018

Closed

Home Health and Hospice

Claims that were originally submitted for processing with a Health Insurance Claim Number (HICN) as the beneficiary identifier are being incorrectly displayed in Direct Data Entry (DDE) with the Medicare Beneficiary Identifier (MBI). Claims should be displaying in DDE with the original identifier submitted on the claim (either the HICN or MBI).

NA

HICN/MBI

06.04.2018

Updates

06.06.2018 – A resolution to this issue was implemented on June 4, 2018.

05.07.2018 – If you use the MBI returned through this display error on claims, the beneficiary will receive a Medicare Summary Notice with the MBI on it, possibly before they receive their new Medicare card containing their MBI. This issue will be resolved no later than May 29, 2018.

For More Information:

MAC Action

No action at this time.

Provider Action

05.07.2018 – To avoid confusion, please do not use a beneficiary's MBI until one of these occur:

  • They present their new Medicare card (which will contain their MBI)
  • The MBI is available through your Medicare Administrative Contractor's secure portal
  • Their MBI is shared through the remittance advice starting in October 2018
Proposed Resolution

05.07.2018 – This issue will be resolved no later than May 29, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.11.17

Closed

Home Health

Type of bill 3XG PEP adjustments caused a negative amount in Value Code 17 which caused overpayments to display on the Summary page of the remittance advice in the Adjustment to Balance Field.

NA

NA

05/21/2018

Updates

05.21.2018 –The April 23, 2018 fix was successful. Since this issue caused overpayments, the CGS will initiate the overpayment recovery process.

05.07.2018 – The April 23, 2018, fix was implemented; however, CGS is researching to ensure the fix was successful.

04.05.2018 – It appears the fix was reassigned and is now scheduled for implementation on April 23, 2018.

03.07.2018 – The March 5, 2018, fix was implemented; however, CGS is researching to ensure the fix was successful.

01.09.2018 – A resolution to this issue is scheduled for implementation on March 5, 2018.

12.11.2017 – The resolution was implemented on November 20, 2017. However, after checking a sample, it was found the issue was still happening. This has been reported to the Fiscal Intermediary Standard System (FISS) maintainer.

11.27.2017 – No additional update at this time.

11.13.2017 – A resolution to prevent this from happening is scheduled for implementation on November 20, 2017. Providers are unable to correct this issue by adjusting the claim

MAC Action

05.21.2018 –CGS will initiate the overpayment recovery process.

11.13.2017 – No action at this time.

Provider Action

11.13.2017 – Do not adjust the claim in an attempt to fix this issue. Further instructions will be forthcoming.

Proposed Resolution

01.09.2018 – A resolution to this issue is scheduled for implementation on March 5, 2018.

11.13.2017 – A resolution to prevent this from happening is scheduled for implementation on November 20, 2017.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.02.2016

Closed

Home Health

01.17.2017 (Home Health) – Some home health claims and adjustments are cycling in FISS in status/location S M90H4 with reason codes E0419, V8029, V8030, and V8031.

03.02.2016 – The issue involving some adjustments (type of bill XXG), continues as previously reported. Refer to the "Resolved Fiscal Intermediary Standard System (FISS) Issues" web page for details.

E0419, V8029, V8030, V8031, and E46#V

NA

05/07/2018

Updates

05.07.2018 – After monitoring the above reason codes, claims and adjustments are processing normally.

03.22.2018 – The issue with reason codes V8029, V8030, V8031, have been resolved. At this time, 50 claims remain suspended with reason code E0419. The Claims department continues to work to process these claims. If you have questions, contact the Provider Contact Center at 1.877.299.4500.

02.06.2018 – A resolution related to reason codes V8030 and V8032 has been scheduled for implementation on March 5, 2018.

02.01.2018 – The CGS Claims department continues to work with the Technical staff. No additional update at this time.

01.09.2018 – No additional update at this time.

12.11.2017 – Although a resolution was implemented on November 6, 2017, claims continue to suspend. Additional research is being done.

11.27.2017 – A resolution was implemented on November 6, 2017 to correct reason code V8031.

11.13.2017 – No additional update at this time.

10.30.2017 – No additional update at this time.

08.01.2017 – Although the July 3, 2017 system release did allow some claims to process from the status/location S M90H1, an additional resolution is needed. At this time, the additional resolution has not been scheduled for release. Please note that CGS continues to explore manual workarounds to allow these claims to process.

05.30.2017 (Updated 06.09.2017) – At this time, adjustments (TOB XXG) continue to suspend in status/location S M90H4 and S M90H1. Additional issues related to the value codes were discovered. FISS maintainers have scheduled a resolution for implementation on July 3, 2017. Please note that this resolution does not address final claims.

12.01.2016 – A resolution to this issue has been scheduled for implementation in April 2017. Claims and adjustments affected by this issue will suspend in status/location S M90H4 with reason code E0419, V8029, V8030, and V8031.

05.06.2016 – The April 25, 2016 system implementation failed to fully resolve this issue. The system maintainer has been informed. As mentioned below, CGS will continue to manually work through the suspended adjustments.

03.02.2016 – A resolution to this issue is scheduled for implementation on April 25, 2016. Until a resolution is implemented, CGS will manually work through the suspended adjustments. Please note that due to the manual process and other limitations, some may not process until the scheduled implementation.

MAC Action

NA

Provider Action

03.22.2018 – No provider action is required.

Proposed Resolution

NA

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.20.2018

Closed

Home Health

Requests for Anticipated Payments (RAPs) are suspending in status/location S M90CW with reason code E61#H.

E61#H

NA

03/08/2018

Updates

03.08.2018 – RAPs are no longer suspending in status/location with reason code E61#H.

MAC Action

03.08.2018 – The CGS Claims department will release the RAPS currently pending the status/location S M90CW with reason code E61#H for processing.

Provider Action

03.08.2018 – No action required.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.25.2018

Closed

All providers

The Interactive Voice Response (IVR) system is not calculating the QMB deductible and coinsurance amounts correctly.

NA

NA

02/12/2018

Updates

02.14.2018 – This issue has been resolved.

02.09.2018 – No additional update at this time.

MAC Action

01.25.2018 – CGS is working to resolve this issue.

Provider Action

02.14.2018 – Providers can now use the IVR (1.877.220.6289) to obtain a breakdown of the deductible and coinsurance amounts.

01.25.2018 – At this time, please contact the home health and hospice Provider Contact Center (PCC) at 1.877.299.4500 for assistance in getting a breakdown of the deductible and coinsurance amounts.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.18.2018

Closed

Hospice

CGS is aware that some adjustments continue to pay the incorrect 60 day 'high' and 'low' Routine Home Care rate

NA

NA

02/19/2018

Updates

02.19.2018 – The previously adjusted claims have been readjusted; therefore, all claims payment should be correct. If you still believe you received an incorrect payment, please review the claim and provide a detailed explanation before contacting the Provider Contact Center (PCC).

02.09.2018 – No additional update at this time.

01.26.2018 – After additional research, it has been determined why previous adjustments did not correct the payment as anticipated. CGS will gather the necessary data and will re-adjust the adjustments that were processed with the incorrect payment.

MAC Action

01.26.2018 – CGS is working to gather the necessary data and will re-adjust the adjustments that were processed with the incorrect payment.

01.18.2018 – CGS is researching this issue and waiting for direction from the Centers for Medicare & Medicaid Services (CMS).

Provider Action

01.26.2018 – No action is required by providers at this time.

01.18.2018 – No action is required by providers at this time.

Proposed Resolution

01.26.2018 – CGS will re-adjust the adjustments that were processed with the incorrect payment.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.21.2017

Closed

Home Health and Hospice

Payers secondary to Medicare aren't able to process some of your direct billed claims due to patient responsibility deductible and coinsurance amounts on the Medicare Remittance Advice (RA) showing zero. Claims automatically crossed over from Medicare to secondary payers aren't impacted.

NA

NA

02.06.2018

Updates

03.16.2018 – CMS issued Change Request (CR) 10494External PDF instructing CGS to initiate non-monetary mass adjustment for QMB claims with a date of receipt prior to December 8, 2017. This will generate "replacement" Medicare RAs that providers can submit to supplemental payers to coordinate benefits as necessary. This CR has an implementation date of September 17, 2018.

02.09.2018 – CMS issued Change Request 10433 and MM10433External PDF which will reintroduce Qualified Medicare Beneficiary (QMB) information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN). CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

01.17.2018 – As indicated in the revised SE1128 article, CMS systems reverted back to the previous display of patient responsibility for QMBs on the Medicare RA.

01.09.2018 – No additional update at this time.

01.03.2018 – Reference SE1128External PDF for additional information.

12.05.2017 – No additional update at this time.

MAC Action

03.16.2018 – CMS issued Change Request (CR) 10494External PDF instructing CGS to initiate non-monetary mass adjustment for QMB claims with a date of receipt prior to December 8, 2017. This will generate "replacement" Medicare RAs that providers can submit to supplemental payers to coordinate benefits as necessary. This CR has an implementation date of September 17, 2018.

Provider Action

03.16.2018 – No action required.

11.21.2017 – Providers may want to hold QMB claims and submit them after December 8. Reference the CMS QMB Remittance Advice IssueExternal PDF announcement for additional information.

Proposed Resolution

03.16.2018 – CMS issued Change Request (CR) 10494 instructing CGS to initiate non-monetary mass adjustment for QMB claims with a date of receipt prior to December 8, 2017. This will generate "replacement" Medicare RAs that providers can submit to supplemental payers to coordinate benefits as necessary. This CR has an implementation date of September 17, 2018.

02.09.2018 – CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

11.21.2017 – On December 8, 2017, CMS systems will revert back to the previous display of patient responsibility for QMBs on the Medicare RA.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.03.2018

Closed

Hospice

When a hospice Notice of Election (NOE) is submitted via EDI, effective with CR 10064External PDF, the data included in the non-required Patient Status and Source fields is not being removed and is causing the NOE to suspend with reason code E2101.

E2101

Patient Status and Source fields

02.12.2018

Updates

02.12.2018 – A resolution was successfully implemented on February 5, 2018. Hospice providers may submit NOEs via EDI, or by using FISS DDE.

02.09.2018 – CGS technical staff are currently testing the implemented system release.

01.17.2018 – Claims are currently suspending in status/location S MHEAT. A process has been put in place to remove the date in the patient status and source fields, until the system release is implemented on February 5, 2018.

MAC Action

01.03.2018 – CGS is exploring options for a work around to allow NOEs to process.

Provider Action

01.03.2018 – CGS recommends that hospice providers submit NOEs using FISS direct data entry (DDE) until a fix to this issue is implemented.

Proposed Resolution

01.03.2018 – The FISS maintainer is aware of this issue. A fix to this issue is scheduled to be installed on February 5, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.03.2018

Closed

Hospice

The Companion Guide created by CMS included the use of the procedure code Q5009 (not otherwise specified code). This required a description in the service line (data element SV202-7); however, this information was not identified as being required in the Companion Guide. As a result, NOEs received without the procedure code description data element will reject in the EDI front-end editing and will be returned via the 277 Claims Acknowledgement Transaction.

NA

Procedure Code

02.12.2018

Updates

02.12.2018 – A resolution to other issues was successfully implemented on February 5, 2018. Hospice providers may submit NOEs via EDI, or by using FISS DDE.

02.09.2018 – No additional update at this time.

01.17.2018 – The Companion GuideExternal PDF has been updated showing the entry of NOE for the data element SV202-7. However, because issues still exist, hospice providers should submit NOEs using FISS direct data entry.

MAC Action

01.03.2018 – No action at this time.

Provider Action

01.03.2018 – CGS recommends that hospice providers submit NOEs using FISS direct data entry (DDE) until a fix to this issue is implemented.

Proposed Resolution

01.03.2018 – CMS is working to revise the Companion Guide requirements to include appropriate data element.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.13.2017

Closed

Hospice

Billing transactions submitted with reopening Type of Bill (TOB) 8XQ are receiving reason code 31411 indicating the occurrence span code 77 is not valid.

31411

Occurrence Span Code 77

01.22.2018

Updates

01.24.2018 – The resolution was implemented on January 22, 2018. The Claims department will release the claims currently pending due to this issue in status/location S M3141 to allow them to continue processing.

01.09.2018 – No additional update at this time.

12.11.2017 – No additional update at this time.

12.05.2017 – A resolution to this issue has been scheduled for implementation on January 22, 2018.

11.27.2017 – No additional update at this time.

11.13.2017 – It has been determined that reason code 31411 was not updated to recognize the reopening TOB (XXQ) as a valid TOB. All billing transactions receiving reason code 31411 with a reopening TOB will be suspended in status/location S M3141. A resolution has been developed; however, it has not been scheduled for implementation.

MAC Action

01.24.2018 – The Claims department will release the claims currently pending due to this issue in status/location S M3141 to allow them to continue processing.

12.05.2017 – Once the resolution is implemented on January 22, 2018, the CGS Claims department will move the claims out of the suspended status/location S M3141 to continue processing.

11.13.2017 – No action at this time.

Provider Action

01.24.2018 – No action required by providers.

11.13.2017 – No action at this time.

Proposed Resolution

12.05.2017 – Once the resolution is implemented on January 22, 2018, the CGS Claims department will move the claims out of the suspended status/location S M3141 to continue processing.

11.13.2017 – A resolution has been developed; however, it has not been scheduled for implementation. All billing transactions receiving reason code 31411 with a reopening TOB will be suspended in status/location S M3141.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.21.2017

Closed

Home Health

Home health claims (32X; excluding 322) with the valid physician specialty codes 18 or 72 are being incorrectly denied with reason code 32072.

32072

01.22.2018

Updates

01.24.2018 – The resolution was implemented on January 22, 2018. Refer to the Provider Action section below for instructions.

01.09.2018 – No additional update. Awaiting the resolution to be implemented on January 22, 2018.

12.05.2017 – A resolution to this issue has been scheduled for implementation on January 22, 2018.

MAC Action

01.24.2018 – See the Provider Action section below. CGS will adjust the affected claims once the reopening request is received.

11.21.2017 – CGS has reported this issue to the Fiscal Intermediary Standard System (FISS).

Provider Action

01.24.2018 – Because it is not possible for CGS to identify the claims that were denied in error, providers need to request a reopening by following the steps below. This issue affected claims that were processed on or after October 2, 2017.

  • Complete the Medicare HHH Reopenings Adjustment Request Form for each claim denied in error.
    • Complete the Provider Information and Beneficiary Information section of the form.
      • Be sure to indicate the correct Document Control Number (DCN)
    • Include the remark, "32072 specialty code issue" in the "Other" portion of the Reason for Request section
    • Supporting documentation is not required.
    • Provide a contact name and phone number and signature.
    • Send completed form to the address provided at the bottom of the form, or fax it to 615-660-5982.
Proposed Resolution

01.09.2018 – A resolution to this issue has been scheduled for implementation on January 22, 2018.

11.21.2017 – A resolution has been developed; however, it has not been scheduled for implementation.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.06.2016

Closed

Hospice

An issue has been identified with the 60 day 'high' and 'low' Routine Home Care rate being applied incorrectly with dates of service on or after January 1, 2016.

NA

NA 12.14.2017
Updates

12.14.2017 – The CGS Claims department is working to complete the adjustments by January 19, 2018 as stated in the SE 17029 article. Refer to the article, "Hospice Claims Requiring Adjustments Update" for additional information.

12.11.2017 – No additional update at this time.

11.27.2017 – No additional update at this time.

11.13.2017 – No additional update at this time.

10.30.2017 – No additional update at this time.

09.28.2017 – Refer to the MAC Action and the Provider Action section below.

05.30.2017 – Refer to the Provider Action section below.

09.28.2016 – In the August 18, 2016, Provider eNewsExternal PDF CMS notified hospices that Medicare Administrative Contractors (MACs) would adjust claims to correct miscounting of routine home care days. Due to incorrect payments, MACs will stop adjustments until a solution is implemented.

09.16.2016 – Refer to the following articles for additional information:

05.06.2016 – The Centers for Medicare & Medicaid Services (CMS) is aware of, and is researching this issue.

MAC Action

09.28.2017 – CGS will initiate the adjustments over the three months following the submission of all lists, concluding the process by January 29, 2018.

Provider Action

12.14.2017 – If you did not submit a list of claims to correct the RHC and SIE payment errors, (not related to transfers) you may proceed and submit your own adjustments. Refer to the article, "Hospice Claims Requiring Adjustments Update" for additional information.

09.28.2017 – The Centers for Medicare & Medicaid Services (CMS) issued the MLN Matters® article SE17029, "Process for Hospices to Submit a List of Claims Requiring Adjustments"External PDF instructing hospice providers to submit a list of claims to be adjusted due to routine home care (RHC) and service intensity add-on (SIA) payment errors. Hospice providers should submit their list of claims to CGS, no later than October 20, 2017, to CGS.MEDICARE.HHH.CLAIMS@cgsadmin.com.

The list of claim information should include only the following:

  • the document control numbers (DCNs) of the claims to be adjusted
  • the dates of service for each claim, and
  • whether the error is related to RHC days or SIA amounts.

DO NOT include personal health information, such as the beneficiary name, and health insurance claim number (HICN).

DO NOT submit a secured email. When your list of claims to be submitted is sent in a secured email, CGS is unable to access the list. Therefore, if you have submitted a secured email, please resend, unsecured.

05.30.2017 – Medicare has corrected most of the system errors associated with 2016 hospice service intensity add-on and RHC payments; however, two issues still remain, which require Hospices to submit adjustments. Refer to the MLN Matters Special Edition article SE17014External PDF for additional information.

Proposed Resolution

09.28.2017 – Refer to the MAC Action and the Provider Action section below.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.13.2017

Closed

Home Health

Negative Pressure Wound Therapy (NPWT) claims billed on a 34X Type of Bill (TOB) are going to the Return to Provider (RTP) incorrectly with reason code 38054.

38054

NPWT Billing Elements 12.11.2017
Updates

12.11.2017 – No further action is required. As instructed below, when billing NPWT claims (34X TOB), enter NPWT in the Remarks field. If your claim goes to the RTP file (T B 9997) with reason code 38054, enter NPWT in the Remarks field (FISS Page 04), and press F9.

11.27.2017 – No additional update at this time.

11.13.2017 – The Fiscal Intermediary Standard System (FISS) is looking at the 34X as a duplicate to the 329 TOB, causing the reason code 38054 to apply.

MAC Action

11.13.2017 – CGS will update the internal edit to suspend NPWT claims to status/location S M3805. If the claim shows NPWT in the REMARKS field (FISS Page 04), CGS will release the claim to continue processing. If the REMARKS field does not include NPWT, CGS will send the claim to RTP.

Provider Action

11.13.2017 – When billing NPWT claims (34X TOB), enter NPWT in the Remarks field. If your claim goes to the RTP file (T B 9997), enter NPWT in the Remarks field (FISS Page 04), and press F9.

Proposed Resolution

11.13.2017 – See Provider Action above.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.21.2017

Closed

Home Health

Home health and hospice claims and Requests for Anticipated Payment (RAPs) are being rejected in error.

U6815, U6816, U6817, U6818

NA 12.11.2017
Updates

12.11.2017 – As earlier reported, CGS initiated the adjustments to the claims that were rejected in error. No further action is required.

11.27.2017 – No additional update at this time.

11.20.2017 – CGS has initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the system release, which was implemented November 6, 2017.

11.13.2017 – The system release, which was scheduled for November 6, 2017, was implemented. CGS will initiate adjustments to the claims that were rejected in error. Please note the Provider Action below.

10.30.2017 – No additional update at this time.

10.09.2017 – See the MAC Action and Provider Action sections below.

09.22.2017 – In addition to claims being rejected in error, Requests for Anticipated Payment (RAPs) were also being rejected in error with reason codes U6815, U6816, U6817, or U6818. CMS has provided instructions for CGS to cancel all the RAPs that were rejected in error between 6/5/17 through 8/7/17.

Once the RAPs have cancelled, CGS will notify providers to resubmit the RAPS.
In addition, within 45 days after the 11/6/17 system release, CGS will initiate claim adjustments that were rejected in error during this time period.

08.21.2017 – The Fiscal Intermediary Standard System (FISS) is aware of this issue and are currently working on a resolution.

MAC Action

12.11.2017 – No further action is required.

11.20.2017 – CGS has initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the system release, which was implemented November 6, 2017.

10.09.2017 – CGS has initiated cancels for all the home health Requests for Anticipated Payment (RAPs) that were rejected in error between 6/5/17 through 8/7/17.

Provider Action

10.09.2017 – Providers need to monitor their remittance advice for the cancelled RAPs that were originally rejected with reason codes U6815, U6816, U6817, or U6818. Once they appear on your RA, please resubmit the RAP to process correctly.

Proposed Resolution

10.09.2017 – A system release is scheduled for November 6, 2017, at which time, CGS will initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the November system release is implemented.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

08.21.2017

Closed

Home Health

Home health no-payment claims submitted with condition code 21 are being denied in error with an incorrect reason code (37253 – no OASIS assessment found). No payment claims do not require an OASIS assessment.

37523

Condition Code 21 09.26.2017
Updates

09.26.2017 – Research revealed that no-payment claims submitted with a 329 type of bill (TOB) will generate an incorrect denial reason code. No-payment claims must be submitted with TOB 320 and condition code 21. For details on submitting no-payment claims, refer to the CGS Home Health No-Payment Billing (Condition Code 21) Web page.

08.21.2017 – The Fiscal Intermediary Standard System (FISS) and the Centers for Medicare & Medicaid Services (CMS) are aware of this issue and are currently working on a resolution.

MAC Action

NA

Provider Action

Bill no-payment claims with the appropriate Type of Bill 320 and condition code 21 to prevent an incorrect denial.

Proposed Resolution

NA

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Reason Code/Status Location

Situation

Status

E94G2

Status/location S M90PP

2/21/2017 (Home Health and Hospice) – Some home health and hospice claims are suspending with reason code E94G2 in status/location S M90PP. FISS is incorrectly applying the reject reason code 32352 and changing the type of bill from 329 to 320.

5/30/2017 – The research done by the CGS Technical team indicated that the E94G2 is not a system issue. Appropriate No-Pay codes will be applied as necessary and the claims will be recycled to continue processing. No action by providers is necessary.

2/21/2017 – (Updated 03/28/2017) The CGS Technical team is researching this issue. CGS Claims staff are manually working the claims to continue processing. Please note, according to the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, §80.2.1.1External PDF) Medicare contractors have 30 days to process clean claims. In the event that claims cannot be processed within 30 days, claims will be paid with interest.

U5601

Return to Provider (RTP) file, T B9997

12/15/2016 (Hospice) – When a hospice claim for pneumococcal pneumonia and influenza vaccine is processed, the monthly claim including hospice services is incorrectly going to the Return to Provider (RTP) file with reason code U5601 indicating the dates of service overlap a previously processed claim.

2/14/2017 – This issue has been resolved. Providers may submit any flu claims that they may be holding.

12/15/2016 – The Centers for Medicare and Medicaid Services (CMS) and the Common Working File (CWF) are aware of this issue.

If your monthly hospice claim is in RTP with reason code U5601 because your vaccination claim has processed, you may cancel (XX8) the vaccination claim. Once canceled, you may F9 the monthly hospice claim from the RTP file to continue processing.

CGS recommends hospices hold their vaccination claims at this time. However, after the monthly hospice claim processes, you may resubmit the vaccine claim and they will be held in status/location SMFLUH until this issue is resolved.

32403 and 32404

Status/location S MFEE4 or in the Return to Provider (RTP) file, T B9997

1/20/2017 (Home Health)– Home health claims that span 2016 and 2017 dates of service, with line item dates of service prior to 1/1/2017 with HCPCS code G0163 or G0164 are incorrectly receiving reason code 32403. HCPCS G0163 and G0164 were retired and are no longer valid for services on or after 1/1/2017; however, they are valid for line item service dates prior to 1/1/2017.

2/1/2017 – This issue has been resolved. Claims suspended in status/location S MFEE4, S MFEES, and S MHCPC will be released to cycle through FISS to continue processing. If you have claims in the Return to Provider (RTP) file related to this issue, press F9 to release the claim to continue processing.

1/20/2017– This issue has been reported to the FISS maintainer.

U5112

Status/location S MU511

10/27/16 (Hospice) – Reason code U5112 is being applied to hospice claims incorrectly.

12/01/16 – The resolution to this issue was implemented on November 21, 2016. Claims are no longer receiving reason code U5211 in error. If you see a claim, other than a NOTR (8XB), in RTP with reason code U5211 after November 21st, please contact the Provider Contact Center.

10/27/16 – The system maintainer is aware of the issue and a resolution is scheduled for production on November 21, 2016.

36458

RTP status / location T B9997

10/27/16 (Hospice) – Some hospice claims with dates of service on or after October 1, 2016, are incorrectly being returned to provider (RTP) indicating that the Core-Based Statistical Area (CBSA) Number is invalid.

11/9/16 – CMS has provided instructions to implement a temporary fix that will allow claims to process. If providers have claims in the RTP file with reason code 36458, please F9 the claim(s) to allow continued processing.

10/27/16 – This issue has been reported and is currently being researched by the system maintainer.

NA

2/2/16 (Hospice) – Hospice claims with dates of service on or after January 1, 2016, may be receiving incorrect Service Intensity Add-on (SIA) payments.

4/19/2016 – CGS has completed the adjustments to correct the SIA payments.

3/2/2016 – The scheduled system release has been implemented. CGS anticipates that CMS will instruct us to adjust these claims to correct payment; however, providers may proceed with submitting adjustments to the claims.

2/2/16 – The FISS maintainers have scheduled a system release for February 22, 2016, to resolve this issue.

NA

1/8/2016 (Home Health) – The Integrated Outpatient Code Editor (I/OCE) is adding 10 payer only value codes (QN – QW) on home health claims that are received on or after January 1 2016.

4/19/2016 – This issue has been resolved by the implementation of the April 2016 quarterly release. Please note, that if you adjust a claim that includes the additional 10 value codes (QN – QW), you will need to remove the value codes and the zero amounts from your adjustment.

1/8/2016 – The Centers for Medicare & Medicaid Services (CMS) is aware of this issue. This issue will be resolved with corrected I/OCE logic, which is scheduled for implementation in the April 2016 quarterly release.

NA

2/2/16 (Home Health) – The HIPPS codes on home health claims with 2015 to current dates of service and 20 or more therapy visits, are recoding incorrectly. The 2nd and 3rd positions of the HIPPS code are being changed when the HIPPS code begins with a 5.

5/6/2016 – CGS has completed all the adjustments related to this issue. The adjustments will process through FISS as usual.

4/19/2016 – CMS issued the MLN Matters® article, MM9608External PDF indicating that this issue will be resolved with the April 25, 2016, implementation of a revised HH Pricer. CGS will adjust home health claims to correct payments.

3/2/2016 – Upon researching this issue, it was identified that there is an issue with pricing home health claims with HIPPS recoding from a 5 to a 5.

2/2/2016 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) for research.

E0419

Status/location S M90H4

8/19/2015 (Home Health) – It appears that the issue involving some adjustments (type of bill XXG), was not resolved as previously reported.

2/5/2016 – A resolution to this issue has been implemented. CGS is working to release claims suspended in status/location S M90H4 with reason code E0419. No action by providers is required.

12/1/2015 – The standard system maintainer has indicated the resolution scheduled for November 23, 2015, did not resolve this issue. An additional system update will be necessary and is currently being researched.

10/23/2015 – A resolution to this issue is scheduled for implementation on November 23, 2015.

8/19/2015 – This issue has been reported to the FISS technical staff for additional research.

11/9/2015 (Home Health) – Some home health claims are processing with the incorrect HIPPS code due to the HIPPS code not recoding correctly.

1/26/2016 – The necessary adjustments are being made and are expected to process in mid-February. If you have a claim that you feel should have been adjusted but was not, please contact the Provider Contact Center (PCC) at 1.877.299.4500 (Option 1).

12/17/2015 – A resolution to this issue will be implemented January 4, 2016. CGS will make the necessary adjustments to claims/adjustments with receipt dates between 10/1/2015 and 1/4/2016 and a provider submitted HIPPS code of 5, and fewer than 20 occurrences of therapy visits (042x, 043x, and 044x). Home health agencies do not need to take any action. These adjustments will be completed within two months of the January 4, 2016, implementation date.

11/9/2015 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) and to the FISS maintainer.

32402 and 32403

Status/location S MFEES

1/28/16 (Home Health and Hospice) – Home Health and Hospice claims are receiving reason code 32402 and/or 32403 incorrectly when the claim includes the HCPC code G0154, G0299, and G0300

1/28/16 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS).

2/2/16 – CMS has provided instructions for CGS to update the HCPC file. This update has been completed, and CGS staff will work to release affected claims from the S MFEES status/location to continue processing. If you have claims in the Return to Provider (RTP) related to this issue, please F9 the claims to allow processing.

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